JACC: CARDIOVASCULAR IMAGING VOL. 11, NO.

11, 2018

ª 2018 BY THE AMERICAN COLLEGE OF CARDIOLOGY FOUNDATION

PUBLISHED BY ELSEVIER

Lung Ultrasound for the Cardiologist

Eugenio Picano, MD, PHD,a Maria Chiara Scali, MD, PHD,b Quirino Ciampi, MD, PHD,c Daniel Lichtenstein, MDd

ABSTRACT

For a cardiologist, lung ultrasound is an add-on to transthoracic echocardiography, just as lung auscultation is part of a
cardiac physical examination. A cardiac 3.5- to 5.0-MHz transducer is generally suitable because the small footprint
makes it ideal for scanning intercostal spaces. The image quality is often adequate, and the lung acoustic window is
always patent. The cumulative increase in imaging time is <1 min for the 2 main applications targeted on pleural water
(pleural effusion) and lung water (pulmonary congestion as multiple B-lines). In these settings, lung ultrasound out-
performs the diagnostic accuracy of the chest radiograph, with a low-cost, portable, real-time, radiation-free method. A
“wet lung” detected by lung ultrasound predicts impending acute heart failure decompensation and may trigger lung
decongestion therapy. The doctors of tomorrow may still listen with a stethoscope to their patient’s lung, but they will
certainly be seeing it with ultrasound. (J Am Coll Cardiol Img 2018;11:1692–705) © 2018 by the American College of
Cardiology Foundation.

LUNG ULTRASOUND IN CARDIOLOGY: neighboring or superimposed scanning fields on the

HISTORICAL BACKGROUND
Two hundred years after Laennec (1), who first
introduced mediated lung auscultation as part of the
physical examination of the heart in 1819, the trans-
ducer follows the same pathway as the stethoscope,
from the cardiac area to lung fields, with several
diagnostic benefits in the same examination. This
may seem obvious now, but for our generation of
cardiologists it took 50 years of transthoracic echo-
cardiography (TTE) practice before we shifted the
transducer by a few centimeters from the cardiac
acoustic window to gain a view of the amazing new
diagnostic world of lung ultrasound.
In the 1990s, lung ultrasound was first proposed
with pioneering applications in the critically ill in a
range of clinical conditions (2), including the detec-
tion of hemodynamic acute pulmonary edema (APE).
It was only in 2004 that TTE was combined with lung
ultrasound to detect pulmonary congestion in pa-
tients with heart failure who were admitted to a car-
diology ward (3).
In retrospect, the technological and cultural gap
between TTE and lung ultrasound was very narrow
and did not require an intuitive mind to bridge it. The
2 techniques share the same equipment, with
left anterior hemithorax. The diagnostic information
provided by lung ultrasound is of obvious clinical
interest to the cardiologist, who is well aware of the
prognostic and therapeutic relevance of extravascular
lung water, and how a real-time assessment of lung
water may provide information complementary to
conventional methods based on physical examination
and chest radiographs to detect pulmonary conges-
tion. In addition, intensivists and cardiologists often
work on the same patients, and there is usually a
close spatial proximity between the intensive care
and coronary units. This logistic setting should
theoretically facilitate the spread of innovative prac-
tices. However, TTE and lung ultrasound remained
divided for decades by an invisible but impenetrable
cultural wall. Standard textbook knowledge told us
that the lung is filled with air (>90%), and air stops
the ultrasound signal because of the very high
impedance mismatch with chest tissues. The clinical
corollary was that “ultrasound imaging is not useful
for evaluation of pulmonary parenchyma” (4). In re-
ality, the lung acoustic window is always open, even
when the cardiac acoustic window for TTE is shut (5).
Although only a limited portion of lung parenchyma
can be visualized, this minute portion is critically
important because most acute life-threatening

From the aCNR Institute of Clinical Physiology, Pisa, Italy; bCardiology Department, Nottola Hospital, Siena, Italy; cCardiology
Division, Fatebenefratelli Hospital, Benevento, Italy; and the dMedical Intensive Care Unit, Ambroise-Paré Hospital, Paris-West
University, Boulogne, France. All authors have reported that they have no relationships relevant to the contents of this paper
to disclose.

Manuscript received January 25, 2018; revised manuscript received May 25, 2018, accepted June 19, 2018.

ISSN 1936-878X/$36.00 https://doi.org/10.1016/j.jcmg.2018.06.023

JACC: CARDIOVASCULAR IMAGING, VOL. 11, NO. 11, 2018
NOVEMBER 2018:1692–705
disorders abut the pleural line: pleural effusions,
pneumothorax, and acute interstitial syndrome in
100% of cases; and lung consolidation in 98.5% of
cases.
Once the cultural wall of impedance bias sur-
rounding ultrasound evaluation of the chest had
fallen, cardiologists learned quickly what intensivists
had known for decades. Lung ultrasound (also called
thoracic ultrasound or chest sonography, but these
labels may include mediastinum and the heart) pro-
vides a highly versatile and valuable diagnostic tool
in many conditions that cardiologists encounter
every day in their practice, from heart failure to pul-
monary embolism. The information on lung water can
be easily obtained at baseline and by serially
following interventions for tracking dynamic changes
in pulmonary congestion and decongestion (6). With
comprehensive, limited, or focused examinations,
lung ultrasound is now ready to be embedded in the
standard TTE, from full functionality platforms per-
formed by certified echocardiographers up to pocket
devices used by nonechocardiographers. It is difficult
to find so much diagnostic gain with so little invest-
ment in terms of technology, training, and time in
other areas of cardiology (7). This review is primarily
aimed at those caring for cardiology patients (cardi-
ologists, emergency room physicians, cardiac
ultrasonographers).
CURRENT METHODOLOGY
For the cardiologist, a lung ultrasound study is an
add-on to a TTE study, and it must be focused, fast,
and factual without becoming an extra examination
requiring excessive additional time, separate
reporting, and supplementary billing. The average
time of a comprehensive TTE cardiac scan is 40 to 45
min, and we can easily add 1 min more to scan the
lung for pleural effusion or pulmonary edema. The
methodology of a heart-driven lung ultrasound ex-
amination can be summarized as follows, regarding
the basic requirements: training, transducer, tech-
nology, technique, and targets of examination
(Table 1).
TRAINING. The American College of Chest Physicians
has defined the knowledge and technical elements
required for competence in lung ultrasound (8). In
our own experience, 1 morning hands-on experience
or even a standardized Internet-based module of 2 h
is sufficient to achieve excellent reproducibility in
identification and quantification of B-lines, even
among lung ultrasound–naive sonographers. They are
among the easiest and most reproducible signs to
recognize in cardiovascular ultrasound, considered to
Picano et al. 1693
Heart-Driven Lung Ultrasound
be “kindergarten” in the echocardiography ABBREVIATIONS
cursus studiorum, whereas the identification AND ACRONYMS
of regional wall motion abnormalities is the
AHF = acute heart failure
more challenging “university” (7).
APE = acute pulmonary edema
TRANSDUCER. The probe is applied perpen-
ARDS = acute respiratory
dicular to the chest wall, in a sublongitudinal distress syndrome
view following rib obliquity. The small foot- BLUE = bedside lung
print of a cardiac transducer makes it espe- ultrasonography in emergency
cially suitable for scanning spaces between PLAPS = posterolateral
ribs, and a 3.5- to 5.0-MHz frequency allows alveolar and/or pleural
syndrome
adequate visualization of subpleural struc-
TTE = transthoracic
tures, although with limited resolution to
echocardiography
locate the pleural line with confidence. Crit-
ical care physicians increasingly use 5-MHz micro-
convex probes that give a better view of the whole
lung, superficial and deep, and allow simple emer-
gency TTE, as well as venous, abdominal, and whole
body urgent approaches (9).
TECHNOLOGY. No Doppler, second harmonic, or
contrast medium is needed (7), and lung ultrasound is
performed at best using simple equipment.
TECHNIQUE. The acoustic window for lung ultra-
sound is always patent, even when TTE is not
feasible. On the left side of the chest, the lung ultra-
sound window is close to TTE apical and parasternal
windows and corresponds to the popular BLUE points
in intensivists’ approach (10), where BLUE stands for
bedside lung ultrasonography in emergency (11).
There are 3 symmetrical regions per lung: 2 anterior
points (upper BLUE point, lower BLUE point); and 1
posterolateral point, at or behind the posterior axil-
lary line, at the level of the lower BLUE point, called
the PLAPS point, where PLAPS stands for posterolat-
eral alveolar and/or pleural syndrome (Figure 1). The
anterior BLUE points are sought for the diagnosis of
pneumothorax and pulmonary edema and are the
elective site for detection of pulmonary congestion at
rest. With stress, there is an additional but important
focus on the third intercostal space in the 2 regions
between the posterior axillary and anterior axillary
lines and the anterior axillary and the midclavicular
lines (12), the “wet spots” where lung water accu-
mulates most during semisupine exercise (Figure 2).
The PLAPS point allows for immediately diagnosis of
most pleural effusions (13) and posterior alveolar
syndromes (14) with >90% sensitivity. The PLAPS
point is accessible in all patients, including venti-
lated, supine, bariatric patients, by using a probe that
can be inserted between this posterolateral part of the
chest and the bed; the most posterior is the best, but
sometimes this is not easy to access, so the most
possible lateral part makes the best compromise for
detecting PLAPS. Once a pleural effusion is detected,
1694 Picano et al. JACC: CARDIOVASCULAR IMAGING, VOL. 11, NO. 11, 2018

Heart-Driven Lung Ultrasound NOVEMBER 2018:1692–705

MAIN SIGNS OF LUNG ULTRASOUND IN

T A B L E 1 Requirements and Technique for Combined TTE and Lung Ultrasound Scanning
PHYSIOLOGY AND DISEASE
Training, Techniques,
and Targets TTE Lung Ultrasound
With lung ultrasound, the lung surface has always a
Training
simple pattern wherever the probe is applied. The
Certification Standardized Deregulated in cardiology
Complexity “University” (complex) “Kindergarten” (easy) whole structure is dynamic and produces physiolog-
Rater variability Good to fair (>20%) Good to excellent (<10%) ical variations in movement from end-inspiration to
Transducer type Cardiac (3.5–5.0 MHz) Cardiac or microconvex 5 MHz end-expiration through the respiratory cycle mirrored
Technology required High-end desirable Simple technology optimal in the pleural movement. The main signs of cardio-
Technique logical interest involve the pleural line, the pleural
Acoustic window 1 Apical PLAPS effusion or consolidation
space, lung motion, the lung interstitium, and the
Acoustic window 2 Parasternal 3 IS, MC, AA, MA for water
lung alveolar space.
Acoustic window 3 Subxiphoid Upper BLUE points for PNT
Patient position Supine Supine or sitting PLEURAL LINE. Normal pattern. The 2 separate
Imaging time 30 min <2 min anatomic structures of parietal and visceral pleura are
Analysis time 10 min <2 min
apposed and, with low-frequency transducers, merge
Emergency setting May reduce data quality Unchanged data quality
into a single pleural line, a 0.2- to 0.3-mm thick
Targets
echogenic, horizontal, smooth specular echo
Target 1, effusion Pericardial effusion Pleural effusion
Target 2, hemodynamics Pulmonary pressures Pulmonary congestion (Figure 3). The reverberation or repetition artifacts
Target 3, others LV and RV systolic function, Interstitial syndrome, behind the pleural line can be horizontal (A-lines) or
diastole, valves, and so on consolidation, PNT vertical (B-lines) images with regular, straight, and
geometric shapes more precisely converging to the
AA ¼ anterior axillary; BLUE ¼ bedside lung ultrasonography in emergency; IS ¼ intercostal space; LV ¼ left
ventricular; MA ¼ midaxillary; MC ¼ midclavicular; PA ¼ posterior axillary; PLAPS ¼ posterolateral alveolar and/ head of the probe (the top of the screen) like parallels
or pleural syndrome; PNT ¼ pneumothorax; RV ¼ right ventricular; TTE ¼ transthoracic echocardiography.
(A-lines) or meridians (B-lines).
Abnormal pattern. In acute respiratory distress syn-
the positive diagnosis is made, and the operator is drome (ARDS) and pneumonia, the fluid exudated by
free to assess the volume of the effusion by moving inflammation is a glue (15), which sticks the lung to
the probe; if no effusion is found, however, time is the parietal pleura, thereby abolishing lung sliding.
spared. Using this simplified approach, lung scanning The pleural line appears thickened and irregular,
can be achieved in far <2 min. For serial examina- possibly because of a small subpleural alveolar syn-
tions, the position (sitting or supine) must be drome (Figure 3). Usually, these static signs come
consistent because pleural and pulmonary lung water together with a single critical dynamic sign, the
changes with posture. Lung ultrasound remains abolition (or severe impairment) of lung sliding. This
feasible and reliable under all hemodynamic and sign is helpful in the differential diagnosis of B-lines
ventilatory conditions, unlike TTE information, in ARDS or pneumonia versus cardiogenic APE (15).
which can deteriorate in acute conditions because of The thickening of the pleural line is the main and
hyperventilation and tachycardia, which make imag- most sensitive sign of lung fibrosis, found, for
ing and interpretation of some parameters (e.g., instance, in rheumatologic disease, and it is best
regional wall motion, diastolic filling) more detected with a high-frequency probe.
challenging. PLEURAL MOVEMENT. Normal pattern. The visceral
TARGETS. For the cardiologist, the main diseases pleura slides over the motionless parietal pleura
targeted by lung ultrasound are characterized by a during breathing. The “lung sliding” is a horizontal,
change in water in the pleural space (pleural effusion) to-and-fro movement, beginning at the pleural line,
or lung parenchyma (pulmonary congestion, at rest synchronous with respiration. There is an obvious
and during stress). In both conditions, lung ultra- vertical gradient in the amplitude of lung sliding,
sound has obvious advantages of sensitivity and which is near zero at the apex and gradually increases
specificity compared with chest radiographs. The up to a maximum near the diaphragm (15). In healthy
BLUE protocol has proposed a standardized approach subjects quietly breathing, the amplitude of lung
to the most common causes of acute respiratory fail- sliding is roughly 10 to 15 mm on the anterior chest
ure, which are in the scope of the cardiologist window at the bases (lower BLUE points).
assessing undifferentiated dyspnea (by decreasing Abnormal pattern. When air separates the 2 pleural
frequency): pneumonia, APE, chronic obstructive layers (pneumothorax), the movement disappears.
pulmonary disease, asthma, pulmonary embolism, When a sticky exudate glues the parietal and the
and pneumothorax (11). visceral pleura (pneumonia, ARDS), the movement is
JACC: CARDIOVASCULAR IMAGING, VOL. 11, NO. 11, 2018 Picano et al. 1695
NOVEMBER 2018:1692–705 Heart-Driven Lung Ultrasound

F I G U R E 1 The BLUE Points

Posterior
axillary
line

Upper
BLUE-point

Heart
(usual PLAPS
point

ca u a m
location)

lo us rag
tio l
h

n)
ap
Lower

Di
(
BLUE-point
Phrenic line
(usual location)

The bedside lung ultrasonography in emergency (BLUE) points used in the BLUE protocol with the patient in the supine or semirecumbent
position: (left) upper BLUE points and lower BLUE points; (right) posterolateral alveolar and/or pleural syndrome (PLAPS) point. Two hands
(of the size of the patient’s hands, thus allowing universal use in all kinds of patients) applied this way usually cover the anterior lung surface
(note the upper finger applied just below the clavicle). The upper BLUE point is defined using the middle of the upper hand. The lower BLUE
point is defined using the middle of the lower palm. This makes a symmetrical, trapezoid definition that follows the lung anatomy, is usually
far from the heart and the abdominal structures, and keeps clinical value. The lateral continuation of the lower BLUE point, as posterior as
possible behind the posterior axillary line, defines the PLAPS point, always located quite a bit above the diaphragm. Modified with permission
from Lichtenstein and Mezière (10).

reduced or abolished. When collagen bundles bridge
the parietal and visceral pleura, the movement is also
reduced, as in pleural adhesions.
PLEURAL CAVITY. Normal pattern. The fluid-filled
space between the 2 specular reflectors of parietal
and visceral pleura is only a potential space under
normal conditions because the 2 pleurae adhere to
each other through the few milliliters of serous fluid,
thus allowing smooth movement of the visceral
pleura during the respiratory cycle (Figure 3).

F I G U R E 2 The 4-Sites Simplified Scan for B-Lines

Lung Ultrasound and TTE Windows (Supine Patient)

right side left side
PA MA AA MC PS MS MS PS MC AA MA PA
PA = Posterior-axillary
IS Yellow:
lung water
MA = Mid-axillary at rest and
II˚ after semi-
supine
AA = Anterior-axillary exercise
III˚
MC = Mid-clavicular
IV˚
PS = Para-sternal
V˚ V4 V5 Black:
Parasternal
MS = Margino-sternal
TTE windows
IS = Inter-costal space

The specific spaces (“wet zones”) to look for interstitial lung water accumulation at rest and after stress with the 4-sites simplified scan. TTE ¼
transthoracic echocardiography. Modified with permission from Scali et al. (12).
1696 Picano et al. JACC: CARDIOVASCULAR IMAGING, VOL. 11, NO. 11, 2018

Heart-Driven Lung Ultrasound NOVEMBER 2018:1692–705

F I G U R E 3 Lung Ultrasound Normal and Abnormal Patterns

Regular pleural line,

A-lines
B-lines

Large pleural
Irregular pleural line,
effusion, lung
B-lines
consolidation

(Upper left) Normal lung surface. The pleural line is thin, and the interstitial tissue does not generate any signal, so all that is seen using
ultrasound is the repetition of the pleural line (A-lines). The A-line indicates air below the pleural line (alveolar, or pneumothorax). If this
pattern is associated, anteriorly and symmetrically, with lung sliding, the air is alveolar gas, and this pattern is called the A profile. At the
posterolateral alveolar and/or pleural syndrome (PLAPS) point, no PLAPS is seen in the normal lung surface, usually A-lines (with lung
sliding), sometimes B-lines are seen. (Upper right) The pulmonary congestion pattern, with a perfectly visible normal pleural line and 4
B-lines. Together with lung sliding (which cannot be appreciated from the frozen frame), if it is anterior, bilateral, symmetrical, this pattern
defines the B profile. (Lower left) Large pleural effusion, with a fully consolidated lower lobe at the posterolateral alveolar and/or pleural
syndrome point. (Lower right) At the anterior bedside lung ultrasonography in emergency (BLUE) points, the pleural line is irregular and
thickened, usually indicating pneumonia and/or acute respiratory distress syndrome.

Abnormal pattern. The pleural effusion noted by ul-
trasound is characterized by the static sign of a space
between the pleural line and the lung line (always
regular, roughly parallel to pleural line, which shows
the visceral pleura) (Figure 3). The dynamic sign is a
variation of this interpleural space within the respi-
ratory cycle, with the inspiratory displacement of the
lung line toward the pleural line and maximal dis-
tance at end-expiration. The static sign is called the
“quad sign,” and the dynamic sign is the “sinusoid
sign” (15). Transudative effusions are anechoic (echo
free). Exudates can be anechoic or echoic, the most
severe cases being usually perfectly echoic (empy-
ema, hemothorax).
LUNG PARENCHYMA. Normal pattern. The normal
lung shows lung sliding with A-lines, which are arti-
factual horizontal reverberations, equidistant from
one another below the pleura, at exact multiples of
the transducer-pleural line (Figure 3). A-lines indicate
that there is air below the pleural line, either 99.5%
air (i.e., normal lung below, which contains trace
amount of water) or 100% air (in pneumothorax) (14).
Abnormal interstitial pattern: multiple B-lines. The B line
is defined according to 7 criteria: 3 constant and 4
almost constant. The B-line is constantly a comet-tail,
vertical artifact. Constantly, it arises from the pleural
line. Constantly, it moves in sync with lung sliding
(when there is lung sliding). Quasi-constantly, the B-
line is well defined and laser-like; long, extending to
the bottom of the screen without fading; erasing A-
lines; and hyperechoic. This precise definition allows
universal recognition in all cases (Figure 3). B-line is
now the preferred name, but these lines are also
called ultrasound lung comets. More than 2 B-lines
JACC: CARDIOVASCULAR IMAGING, VOL. 11, NO. 11, 2018
NOVEMBER 2018:1692–705
per intercostal space have been called lung rockets
(15). In some locations, 1 or 2 B-lines are physiolog-
ical, for instance, anteriorly corresponding to lung
fissures or lung rockets at the bases (likely natural
gravity). Ultrasound interstitial syndrome is defined
by lung rockets. It can be diffuse at the whole chest
wall or symmetrical and associated with conserved
lung sliding in the case of cardiogenic APE. This very
precise pattern is called the B profile in the BLUE
protocol (11). It can be diffuse but associated with
abolished or very decreased lung sliding and labeled
the B0 profile (11) in some cases of pneumonia and/or
ARDS. It can be localized, usually in infectious or in-
flammatory processes (pneumonia, ARDS), and
labeled the A/B profile.
Ultrasound multiple B-lines are the equivalent of
the radiological interstitial syndrome (Kerley lines
and more). We see interstitial syndrome, in acute
conditions, in 2 main diagnoses with opposed man-
agement: cardiogenic APE and pneumonia or ARDS.
Cardiogenic APE is associated with normal lung
sliding, which is often reduced or abolished in
pneumonia or ARDS.
B-lines must not be mixed up with Z-lines, which
are frequently observed as bundle-shaped reflections
arising from the pleural line, but that—unlike true B-
lines—do not erase A-lines, are ill-defined, are less
echogenic than the pleural line, are short, and do not
move in synchrony with respiration (15).
Abnormal alveolar pattern: lung consolidation. In some
conditions, the extreme progression of the interstitial
syndrome leads to the consolidation process with an
echogenic lung, with a tissue texture similar to that of
spleen or liver, the result of replacement of air in the
alveolar space with material other than air, usually
water, pus, or blood (15) (Figure 3). Lung consolida-
tion can have a variety of causes, including alveolar
cardiogenic APE, pneumonia, lung infarction, cancer,
lung contusion, and obstructive atelectasis. In some
etiologies, such as drowning or aspiration pneumo-
nitis, the fluid comes directly to fill the alveoli first,
and the initial presentation is lung consolidation,
without the usual initial phase of interstitial syn-
drome. Lung consolidations may arise in any site,
and, although only the peripheral part of the lungs
can be visualized by ultrasound, 98.5% of consolida-
tions touch the pleura, and 90% of cases locate at the
PLAPS point (14).
PLEURAL EFFUSION IN HEART FAILURE
PATHOPHYSIOLOGICAL MEANING. Elevated left
atrial pressure in left-sided heart failure may cause
Picano et al. 1697
Heart-Driven Lung Ultrasound
pleural effusion only after pulmonary edema has
developed (16,17). Elevated right atrial pressure in
right-sided heart failure can increase the pressure in
the thoracic duct, thus limiting the volume of
lymphatic drainage from the pleural space to the right
atrium through the superior vena cava (16–19).
BEDSIDE RECOGNITION. The main signs on physical
examination are reduced air entry and dullness to
percussion at lung bases (20). In up to 20% of pa-
tients with acute heart failure (AHF), the chest
radiograph is nearly normal, and the sensitivity of
the method is less than one-half compared with lung
ultrasound, especially for mild to moderate pleural
effusions (20).
METHODOLOGY. Semiquantitative grading of the
amount of pleural effusion is possible by measuring
the maximal expiratory interpleural distance from the
pleural line to the lung line on the posterior axillary
line with the patient in the supine position (13) or the
paravertebral, scapular, posterior axillary, or medial
axillary lines in the sitting position (21). The amount
of pleural effusion can be scored as trivial (<2 mm),
small (2 to 15 mm, too small to tap), moderate (15 to 25
mm), or large (>25 mm) (Table 2).
DIAGNOSTIC, PROGNOSTIC, AND THERAPEUTIC
IMPLICATIONS. The prevalence of pleural effusion
may range anywhere between 56% and 90% in AHF,
30% and 60% at pre-discharge, 10% and 70% in
outpatients with chronic stable heart failure, or
25% in patients with isolated right-sided heart failure
(10,21–31) (Table 3). The main TTE predictor of
pleural effusion is the increased systolic pulmonary
arterial pressure (31).
In patients with heart failure, the presence of
pleural effusion is associated with a higher rehospi-
talization rate (26) and clearly worse quality of life,
which has improved after reduction of pleural
effusion with medical therapy (30). In patients with
AHF and pleural effusion, thoracentesis with fluid
evacuation may be considered if feasible to alleviate
dyspnea (20). For thoracentesis, a $15-mm inter-
pleural inspiratory distance is required (13); the nee-
dle is inserted after careful check that 6 organs are not
in the pathway of the needle: the diaphragm, of
course, but also the heart, descending aorta, spleen,
liver, and lung. The quantification is especially
important for assessing variations in the same patient
in natural history or following intervention. Lung
ultrasound is ideal for guiding thoracentesis and
draining effusions. The absence of a virtual space
after the procedure (interpleural space >10 mm) re-
flects an incomplete procedure.
1698 Picano et al. JACC: CARDIOVASCULAR IMAGING, VOL. 11, NO. 11, 2018

Heart-Driven Lung Ultrasound NOVEMBER 2018:1692–705

knows that the patient can have cardiogenic APE,

T A B L E 2 Pericardial and Pleural Effusions: Similarities and Differences by Ultrasound
ARDS or pneumonia, or, rarely, any chronic intersti-
Pericardial Pleural tial disease. The physician will use the profiles of the
Measurements Effusion Effusion
BLUE protocol for refining the diagnosis: lung sliding
TTE, descending aorta Anterior Posterior
associated, making at the anterior wall the B profile,
Temporal change With cardiac cycle With respiratory cycle
Spatial change (supine-sitting) Absent Present
highly accurate for cardiogenic APE; or lung sliding
Where to measure Parasternal apical views PLAPS point abolished, making the B 0 profile, highly specific to
Pathophysiology in HF Right atrial hypertension Right or left atrial hypertension pneumonia or ARDS. In spite of these caveats, the
Normal value of serosal fluid <50 ml <25 ml (for each lung) technique is now the best available for bedside
Size detection of pulmonary congestion.
Trivial Only systolic <2 mm
METHODOLOGY. The comprehensive 28-site scan on
Small <10 mm (50–100 ml) 2–15 mm (too small to tap)
Moderate 10–20 mm (100–500 ml) 15–25 mm the anterolateral chest was initially proposed in a
Large >20 mm (>500 ml) >25 mm (>500 ml) cardiologic setting in 2004 (3) and adopted in
research studies, but it was still too time-consuming
HF ¼ heart failure; other abbreviations as in Table 1.
for routine use in real-world laboratories, especially
during stress echocardiography, when the time pres-
sure is higher (7). Similar information can be obtained
PULMONARY CONGESTION
in much less time with a simplified 4-site scan,
including only the “wet spots” with most B-lines
PATHOPHYSIOLOGICAL MEANING. The sequence of
(Figure 2). In this way lung ultrasound mapping does
events leading to APE during heart failure can be
not interfere with electrocardiographic leads and
conceptualized as a cascade—the so-called lung water
takes only 20 s to be completed (10–12).
cascade—whose sequence was unveiled with the
advent of lung ultrasound (32). The initiating events DIAGNOSTIC, PROGNOSTIC, AND THERAPEUTIC
of the cascade are the increases in left ventricular IMPLICATIONS. AHF accounts for about 1 million
end-diastolic pressure and pulmonary capillary emergency department visits in the United States,
wedge pressure (hemodynamic congestion), eventu- and even when cardiac peptides are incorporated into
ally leading to the imbalance of Starling’s equilibrium the clinical work-up of acute dyspnea, the misclassi-
in the alveolar capillary barrier, which is the pre- fication rate remains at 14% to 29% (37). As shown by
requisite for increased accumulation of lung water a recent meta-analysis recruiting 1,914 patients (37),
(Figure 4). In between hemodynamic and clinical the B profile identifies the cardiogenic origin of dys-
pulmonary congestion, the intermediate event is pnea with 85% sensitivity and 92% specificity (11,37–
interstitial pulmonary congestion detectable by lung 49), superior to pleural effusion and TTE (Table 4),
ultrasound as multiple B-lines (33), linked bio- and comparable to cardiac natriuretic peptides (37–
physically to an increased water-to-air ratio per unit 41). The variability of reported specificities (ranging
of lung volume tissue in the subpleural interlobular from 45% to 97%) likely reflects the selection criteria
septa (7). adopted in the different studies, with high pre-test
BEDSIDE RECOGNITION. Pulmonary congestion is probability of cardiogenic origin in critically ill pa-
the key manifestation of impending AHF, but the tients admitted to intensive care units (11) and low to
clinical, auscultatory, and chest radiographic findings intermediate pre-test probability in clinically stable
are all late, insensitive, and unspecific signs of pul- patients evaluated on admission to the emergency
monary congestion (34). The reproducibility of the department (38).
findings is poor for crackles and moderate for chest The B profile is useful to track dynamic changes in
radiography, but high for B-lines (35). Quantification pulmonary congestion in response to treatment
is easier and more effective for lung ultrasound, and (3,36), and its persistence at pre-discharge or in clin-
it is based on the number of B-lines per space and ically stable outpatients with heart failure is predic-
spatial extension. Changes in B-lines are very quick to tive of heart failure hospitalization or death (22–30).
appear (for instance, during exercise or a volume The key question is whether B profile can be used
challenge) and to disappear (for instance, with di- as a surrogate endpoint to guide interventions, such
uretics or dialysis), and therefore they must be as increase in diuretic therapy in patients with heart
interpreted in view of previous interventions (36). failure or of dialysis rate in patients with advanced
Multiple B-lines (lung rockets) are not designed for chronic kidney disease. Several large-scale random-
identifying a disease, but rather a syndrome: inter- ized studies are in progress (NCT02310061,
stitial syndrome. From this basis, the physician NCT03262571, NCT02959372, NCT03136198).
JACC: CARDIOVASCULAR IMAGING, VOL. 11, NO. 11, 2018 Picano et al. 1699
NOVEMBER 2018:1692–705 Heart-Driven Lung Ultrasound

T A B L E 3 Lung Ultrasound in Left- and Right-Sided Heart Failure

First Author, Pleural

Year (Ref. #) Patients Effusion B Profile Main Finding

Morales-Rull, 2018 (31) 3,245 AHF inpatients 56% N/A SPAP >55 mm Hg predicts pleural effusion
Gundersen, 2017 (30) 62 CHF outpatients 42% N/A Pleural effusion predicts quality of life
Scali, 2017 (10) 103 CHF patients N/A 58% B profile predicts events
Miglioranza, 2017 (29) 97 CHF outpatients N/A 68% B profile predicts events
Platz, 2016 (28) 185 CHF outpatients N/A 32% B profile predicts events
Cogliati, 2016 (27) 149 AHF pre-discharge 36% 64% B profile predicts events
Gustaffson, 2015 (26) 104 CHF outpatients 10% 27% Pleural effusion and B profile predict events
Coiro, 2015 (25) 60 AHF pre-discharge N/A 30% B profile predicts readmission
Gargani, 2015 (24) 99 AHF pre-discharge 24% 40% B profile predicts readmission
Zoccali, 2013 (23) 392 patients undergoing hemodialysis N/A 59% B profile predicts death
Luo, 2011 (19) 89 patients with connective tissue disease 39%* N/A Pleural effusion with RHF
Tang, 2009 (18) 147 patients with PAH 21%* N/A Pleural effusion with RHF
Lichtenstein, 2008 (11) 64 patients with acute respiratory failure N/A 97% Patients in ICU
Frassi, 2007 (22) 290 inpatients (chest pain or dyspnea) N/A 47% B profile predicts events
Jambrik, 2004 (3) 121 CCU inpatients 15%† 68% SPAP and E/e0 predict B profile
Kataoka, 2000 (21) 60 AHF inpatients 91% N/A 41% with pleural effusion by chest radiograph
Wiener-Kronish, 1985 (17) 37 AHF inpatients 51% N/A Left atrial pressure higher in pleural effusion

*Chest radiograph, computed tomography, lung ultrasound, or autopsy. †Chest radiograph.

AHF ¼ acute heart failure; CCU ¼ coronary care unit; CHF ¼ chronic heart failure; ICU ¼ intensive care unit; N/A ¼ not available; PAH ¼ pulmonary arterial hypertension;
RHF ¼ right-sided heart failure; SPAP ¼ systolic pulmonary arterial pressure.

Lung ultrasound is a useful adjunct to TTE dur- different sign (B-lines rather than regional wall
ing stress echocardiography (10,50,51), by providing motion abnormalities), and in a different time
information on a different pathophysiological target window (after rather than at peak stress). As a
(alveolar-capillary barrier rather than physiologi- parameter, B-lines are more feasible, simpler to
cally critical epicardial artery stenosis), with a image and to measure, and inherently more

F I G U R E 4 The Lung Water Cascade

THE LUNG WATER CASCADE

Stable Chronic Heart Failure
Events

Wedge pressure rise Starling equation unbalance Asymptomatic hemodynamic congestion

STRESS Stress B-lines

Lung Ultrasound
Asymptomatic pulmonary congestion

REST B-lines
Lung Ultrasound

SYMPTOMS/SIGNS Clinical congestion

Crackles/Dyspnea/Weight gain

Acute decompensated Heart Failure

Time
(hours, days or weeks)

Hemodynamic congestion is the early event before the imaging sign (multiple B-lines) of pulmonary congestion. Stress B-lines are an earlier
event than resting B-lines. Only after hours, days, or weeks is the clinical congestion apparent. The therapeutic countermeasures are likely
more effective when initiated at the early, pre-symptomatic and pre-radiologic, silent stages of the cascade.
1700 Picano et al. JACC: CARDIOVASCULAR IMAGING, VOL. 11, NO. 11, 2018

Heart-Driven Lung Ultrasound NOVEMBER 2018:1692–705

quantitative than regional wall motion. The accu-

T A B L E 4 Lung Ultrasound to Identify Acute Heart Failure in
Patients With Dyspnea
mulation of lung water during exercise is correlated
with more advanced functional forms of heart
First Author, B Profile
Year (Ref. #) N (S, Sp) TTE
failure and worse prognosis in patients with heart
Ohman, 2017 (49) 100 100, 95 0
E/e >15
failure with reduced ejection function (10), and it is
Sforza, 2017 (48) 68 92, 80 EF <40%, IVC found also in patients with heart failure and
Pivetta, 2015 (47) 1,005 97, 97 N/A preserved ejection fraction (51) (Figure 5, Online
Russell, 2015 (46) 99 69, 83 EF <45% Video 1).
Anderson, 2013 (45) 101 70, 75 EF <40%, IVC
Cibinel, 2012 (44) 56 94, 84 N/A
PULMONARY EMBOLISM
Vitturi, 2011 (43) 152 97, 75 Larger EDV, lower EF
Prosen, 2011 (42) 248 100, 95 N/A
Lung ultrasound usually shows normal anterior
Nazerian, 2010 (41) 145 N/A Dt, EF <50%
Wang, 2010 (40) 84 N/A EDV, EF A-lines and lung sliding (i.e., A profile), often
Liteplo, 2009 (39) 100 58, 85 N/A accompanied by posterior lung consolidation and
Gargani, 2008 (38) 149 97, 45 N/A pleural effusion (11). Venous ultrasonography (with
Lichtenstein, 2008 (11) 301 97, 95 N/A compression in cases when thrombosis is not seen
directly) shows deep vein thrombosis with good
Dt ¼ deceleration time of E wave <130 ms on pulsed Doppler analysis of mitral
inflow; EDV ¼ end-diastolic volume; IVC ¼ inferior vena cava with diameter >2.0 sensitivity (11). TTE may detect (with high speci-
cm and variation of size with breathing <50%; S ¼ sensitivity; Sp ¼ specificity;
ficity but low sensitivity) prognostically relevant
other abbreviations as in Tables 1 and 3.
right ventricular overload and, rarely, the

F I G U R E 5 Stress Lung Ultrasound Patterns

TTE-Lung Ultrasound Stress Echo

NON-ISCHEMIC HEART ISCHEMIC HEART

RWMA

DRY LUNG WET LUNG

B-lines

CAD HFrEF HFpEF Aortic Valve Disease Mitral Valve Disease Extreme Physiology HCM

The results of dual imaging (transthoracic echocardiography [TTE] and lung ultrasound) during stress echocardiography (stress echo) identify
any combination of transthoracic echocardiography and lung ultrasound findings: ischemic (with regional wall motion abnormalities) or non-
ischemic heart by transthoracic echocardiography; and dry (with A-lines) or wet (with acute increase of B-lines) lung by lung ultrasound (with
cardiac probe). In the box in the middle, the estimated relative frequency of different patients observed in a high-volume stress echocardi-
ography laboratory with potential sources of stress B-lines. Also see Online Video 1. CAD ¼ coronary artery disease; HCM ¼ hypertrophic
cardiomyopathy; HFpEF ¼ heart failure with preserved ejection fraction; HFrEF ¼ heart failure with reduced ejection fraction; RWMA ¼ regional
wall motion abnormality.
JACC: CARDIOVASCULAR IMAGING, VOL. 11, NO. 11, 2018 Picano et al. 1701
NOVEMBER 2018:1692–705 Heart-Driven Lung Ultrasound

T A B L E 5 Wet Versus Dry B-Lines T A B L E 6 Differential Diagnosis of Cardiogenic APE Versus ARDS

Feature Wet (Water) Dry (Fibrosis) Feature Cardiogenic APE ARDS

Pleural line Regular, thin Irregular, thickened Multiple B-line distribution Anterior diffuse* Sometimes random†
Pleural movement Normal sliding Reduced sliding Right and left lung Symmetrical Sometimes spared areas†
Pleural effusion Frequent, bilateral Only trivial Anterior pleural line Regular, thin Sometimes irregular, thickened‡
From supine to upright Decrease (s) No change Pleural movement Normal sliding Sometimes reduced sliding§
Exercise Increase (min) No change Pleural effusion Frequent, bilateral Sometimes present
Diuretics Decrease (h) No change Dependent consolidation Usually present Usually present
Nondependent (anterior) Never visible Sometimes present
consolidation
TTE, LV function Severely abnormal Often normal
pathognomonic sign of a mobile serpentine
thrombus in the right side of the heart or the pul- *Corresponds to the B profile of the BLUE protocol. †Corresponds to the A/B profile of the BLUE protocol.
monary artery. Triple ultrasound imaging of heart, ‡Corresponds to the C profile of the BLUE protocol. §Corresponds to the B0 profile of the BLUE protocol.
APE ¼ acute pulmonary edema; ARDS ¼ acute respiratory distress syndrome; other abbreviations as in Table 1.
lung, and veins may have a role as a first-line add-
on to clinical probability scores and D-dimer testing
(52). translate into specific diagnosis of disease (Table 7),
PRIMARY PULMONARY DISEASES: obviously after integration with the clinical presen-
INTERSTITIAL LUNG DISEASES, tation, TTE, venous ultrasonography for deep vein
PNEUMONIA AND ARDS, PNEUMOTHORAX thrombosis detection, and others.

LUNG ULTRASOUND IN SCIENTIFIC

Different primary pulmonary diseases are present as SOCIETIES’ RECOMMENDATIONS
comorbidities in heart failure or as causes of dyspnea
suspected to be cardiac in origin. Lung ultrasound is Ultrasound guidance has been “strongly recom-
helpful in recognizing these diseases. mended” since 2010 by the British Thoracic Society
Pulmonary interstitial fibrosis with lung rockets for all pleural procedures with pleural fluid because it
accompanied by a thickened or irregular pleural line is associated with a lower failure rate and rate of
can be found in 20% to 50% of patients with systemic complications such as pneumothorax and bleeding
sclerosis and, less frequently, in other rheumatologic (56). It is becoming increasingly difficult to justify
diseases (53). Fibrotic (“dry”) B-lines are not performing these procedures without ultrasound
increased by exercise or decreased by upright posi- guidance (57).
tion or diuretic challenge (Table 5). European Association of Cardiovascular Imaging
With lung ultrasound, pneumonia and ARDS recommendations for use of pocket-size devices
appear, roughly, as a single entity (11,54). ARDS can explicitly list “semi-quantification of extra-vascular
be separated from cardiogenic APE on the basis of lung water” with B profile among the top 8 in-
several lung ultrasound and TTE features, summa- dications (58). In emergency echography, the absence
rized in Table 6. of B profile excludes cardiogenic edema with a
As opposed to what happens for water in pleural
effusion, in pneumothorax air tends to accumulate
according to antigravity laws in the least dependent T A B L E 7 From Lung Ultrasound Signs to Specific Diseases
part of the chest. The ultrasound diagnosis of pneu-
Lung Pleural Line Pleural Anterior Lung
mothorax is based on 2 sequential signs. The first is Diagnosis BLUE Profile Sliding Changes Effusion Consolidation Point
the anterior detection of abolished lung sliding with AHPE B þ  þ  
the complete absence of B-line (called A 0 profile in the Pneumonia or ARDS B’, A/B, C, PLAPS  þ þ  
BLUE protocol). The second sequential sign, to be Pulmonary embolism A with DVT þ  þ  
sought only in presence of an A 0 profile, is the Pneumothorax A’     þ
COPD or asthma Nude þ    
detection of the lung point, defined as the sudden
0 ILF B, B’, C  þ   
replacement of the A profile by any other pattern,
usually lung sliding or B-lines (11,55). Terminology modified from the BLUE protocol (11): A profile ¼ normal anterior A-lines and lung sliding; A’
profile ¼ anterior A-lines and abolished lung sliding (plus lung point ¼ pneumothorax); B profile ¼ diffuse
FROM LUNG ULTRASOUND SIGNS TO anterior B-lines and preserved lung sliding; B’ profile ¼ diffuse anterior B-lines and reduced lung sliding; A/B
profile ¼ mixed and balanced A and B profiles; C profile ¼ anterior lung consolidation; nude profile ¼ everything
SPECIFIC DISEASES normal.
AHPE ¼ acute hemodynamic pulmonary edema; COPD ¼ chronic obstructive pulmonary disease; DVT ¼ deep
vein thrombosis at venous ultrasonography; ILF ¼ interstitial lung fibrosis; þ ¼ present,  ¼ absent or reduced;
Different diseases can be identified by lung ultra- other abbreviations as in Table 1.
sound on the basis of the main signs that may
1702 Picano et al. JACC: CARDIOVASCULAR IMAGING, VOL. 11, NO. 11, 2018

Heart-Driven Lung Ultrasound NOVEMBER 2018:1692–705

C E NT R AL IL L U STR AT IO N The Shape of Lung Water

Picano, E. et al. J Am Coll Cardiol Img. 2018;11(11):1692–705.

(Center) The normal pattern seen by transthoracic echocardiography and lung ultrasound, with (top center) normal left-sided filling pressures (normal mitral inflow
pattern with E/A ratio >1), (middle center) normal right-sided filling pressures (inferior vena cava diameter <21 mm, collapsing >50% with a sniff); and (bottom
center) A profile (with A-lines at the anterior chest wall) at lung ultrasound. (Right) The left-sided heart failure pattern seen by transthoracic echocardiography and
lung ultrasound, with (top right) increased left-sided filling pressures (E-wave deceleration time <160 ms with restrictive filling pattern), (middle right) B profile, and
(bottom right) pleural effusion. (Left) The right-sided heart failure pattern seen by transthoracic echocardiography and lung ultrasound. Transthoracic echocar-
diography shows increased right-sided pressures: (top left) tricuspid regurgitant jet at color Doppler; (middle left) systolic pulmonary arterial pressure is 67 mm Hg,
estimated with continuous-wave Doppler from tricuspid regurgitant jet velocity. (Bottom left) Lung ultrasound shows pleural effusion. White asterisks indicate the
pleural line. On the aligned M-mode image, the upper stratified pattern is separated by the lower sandy pattern by the pleural line.

negative predictive value close to 100% (11,59). The
2016 guidelines on heart failure of the European
Society of Cardiology recommend lung ultrasound
among diagnostic tests in heart failure (Class IIb,
Level of Evidence: C) as a test that may be considered
in patients with AHF to confirm pulmonary conges-
tion and pleural transudate (20). In patients with
AHF, in 2015 lung ultrasound was recommended by
the European Society of Cardiology as a first-line
diagnostic test to assess pulmonary congestion in
suspected AHF because “in reasonably expert hands
it can be equally or more informative than chest X-ray
allowing also an important time-saving” (60). The
2017 expert consensus of the AHF group of the Eu-
ropean Society of Cardiology concluded that “TTE
and lung ultrasound can assist in the rapid assess-
ment of patients with acute dyspnea and hypotension
and have the potential to transform the way in which
JACC: CARDIOVASCULAR IMAGING, VOL. 11, NO. 11, 2018
NOVEMBER 2018:1692–705
the clinicians assess and manage critically ill patients
with AHF and cardiogenic shock” (61).
According to the 2016 joint European Association
of Cardiovascular Imaging and American Society of
Echocardiography recommendations, during exercise
stress echocardiography the acute increase in B-lines
detected by lung ultrasound is a feasible way for
demonstrating that the symptom “dyspnea when
exercising” is related to pulmonary congestion sec-
ondary to backward heart failure (62).
CURRENT LIMITATIONS
Severe subcutaneous emphysema can be an absolute
hindrance. Dressings should be limited for favoring
ultrasound studies. Morbid obesity is not a limitation
for several areas of lung ultrasound, mainly detection
of A profile, A 0 profile, B profile, and B 0 profile (15).
Lung rockets reflect the presence of an interstitial
syndrome that can be caused by water, inflamma-
tion, or fibrosis, but integration with clinical
presentation, systematic application of lung ultra-
sound with the BLUE protocol, and association with
TTE allow the clinician to identify the underlying
etiologic factors and to answer the clinical question
most of the time (11).
Lung ultrasound is currently used by many
different medical disciplines, from cardiology to
intensive care, from pneumology to nephrology, from
rheumatology to sports medicine. This range adds
appeal to the technique, but it may pose communi-
cation difficulties related to heterogeneity
terminology, execution, and reporting, and better
harmonization is needed (7). For the past 3 decades,
standardized labels for lung ultrasound have been
refined for maximal efficiency in a field made free of
any confusion (11,15).
Lung ultrasound can reduce medicolegal risk by
shortening the time to diagnosis in patients with life-
threatening conditions. The best defense against
litigation is to follow training strictly. Malpractice
lawsuits have been filed for not performing the ex-
amination in a timely manner (63).
PERSPECTIVES
The image texture is, at least in principle, suitable for
treatment with video-densitometric analysis, and
lung water software is already included in some
commercially available instruments to provide
quantitative support to B-line reading. This option is
attractive, but as in any field, and especially in im-
aging, checking the quantitative, machine-generated
Picano et al. 1703
Heart-Driven Lung Ultrasound
findings using experience, prudence, and clinical
wisdom is always necessary.
Large scale, prospective, international, multi-
center, effectiveness studies are currently ongoing
with rest and stress B-lines in known or suspected
heart failure and coronary artery disease in the Stress
Echo 2020 study, which is planning to recruit 10,000
patients within the year 2020 with the new standard
of dual imaging, including regional wall motion and
B-lines (64).
Randomized outcome studies are needed to assess
the value of lung ultrasound are needed to reduce
mortality in patients with either chronic heart failure
or acute circulatory failure.
CONCLUSIONS
After opening the acoustic window on lung paren-
chyma, the cardiologist discovers unique information
that will soon induce a durable mutation in the
structure of cardiac ultrasound examination,
destined to become a cardiopulmonary (TTE-lung
ultrasound) study. Now is the appropriate time for
professional cardiology and echocardiography
societies to incorporate lung ultrasound into the
mainstream of core teaching, certification, and
reporting in TTE. Lung ultrasound can provide
unique information in the cardiology ward, intensive
care unit, emergency room, echocardiography labo-
ratory, stress testing laboratory, outpatient clinic,
and perhaps especially in home care with handheld
devices in patients with heart failure (Central Illus-
of
tration). The use of lung ultrasound will reduce the
use of techniques based on ionizing radiation, such as
chest radiography or computed tomography, thereby
contributing to minimize the cumulative burden of
unwanted effects of radiation exposure, especially
relevant in cardiology patients (65). A “wet lung”
detected as B profile by lung ultrasound, at rest or
after stress, in a stable patient with chronic heart
failure predicts impending AHF decompensation and
may trigger lung decongestion therapy. No cardiolo-
gist would evaluate a patient with heart failure
without listening to lung fields for crackles or a
pleural effusion. In the same way, today no compre-
hensive, limited, or focused TTE examination will be
considered complete without a short but efficient
assessment of the lung.
ADDRESS FOR CORRESPONDENCE: Dr. Eugenio Pic-
ano, Institute of Clinical Physiology, Italian National
Research Council, Via Moruzzi 1, 56124 Pisa, Italy.
E-mail: picano@ifc.cnr.it.
1704 Picano et al.
Heart-Driven Lung Ultrasound
REFERENCES
1. Laënnec RTH. Traité de l’auscultation médiate,
ou traité du diagnostic des maladies des poumons
et du cœur. Paris, France: J.A. Brosson & J.S.
Chaudé, 1819. New York, NY: Hafner, 1962.
2. Lichtenstein D, Mézière G, Biderman P,
Gepner A, Barré O. The comet-tail artifact. An ul-
trasound sign of alveolar-interstitial syndrome.
Am J Respir Crit Care Med 1997;156:1640–6.
3. Jambrik Z, Monti S, Coppola V, Agricola E,
Mottola G, Picano E. Usefulness of ultrasound lung
comets as a nonradiologic sign of extravascular
lung water. Am J Cardiol 2004;93:1265–70.
4. Longo D, Fauci AS, Kasper DL, Hauser SK,
Jameson JL, Loscalzo J, editors. Harrison’s Prin-
ciples of Internal Medicine. 18th ed. New York,
NY: McGraw-Hill, 2011. Part 11, Section 1, Chap-
ter 253.
5. Volpicelli G, Elbarbary M, Blaivas M, et al., In-
ternational Liaison Committee on Lung Ultrasound
for International Consensus Conference on Lung
Ultrasound. International evidence-based recom-
mendations for point-of-care lung ultrasound.
Intensive Care Med 2012;38:577–91.
6. Picano E, Frassi F, Agricola E, Gligorova S,
Gargani L, Mottola G. Ultrasound lung comets: a
clinically useful sign of extravascular lung water.
J Am Soc Echocardiogr 2006;19:356–63.
7. Picano E, Pellikka PA. Ultrasound of extravas-
cular lung water: a new standard for pulmonary
congestion. Eur Heart J 2016;37:2097–104.
8. Mayo PH, Beaulieu Y, Doelken P, et al. American
College of Chest Physicians/La Société de Réan-
imation de Langue Française statement on
competence in critical care ultrasonography. Chest
2009;135:1050–60.
9. Lichtenstein D. The probe. In: Lung Ultrasound
in the Critically Ill – The BLUE-Protocol. Heidel-
berg, Germany: Springer, 2016; p 23–35.
10. Scali MC, Cortigiani L, Simionuc A, Gregori D,
Marzilli M, Picano E. Exercise-induced B-lines
identify worse functional and prognostic stage in
heart failure patients with depressed left ventric-
ular ejection fraction. Eur J Heart Failure 2017;19:
1468–78.
11. Lichtenstein D, Mézière G. Relevance of lung
ultrasound in the diagnosis of acute respiratory
failure: the BLUE protocol. Chest 2008;134:
117–25.
12. Scali MC, Zagatina A, Simova I, et al. B-lines
with lung ultrasound: the optimal scan technique
at rest and during stress Ultrasound Med Biol
2017;43:2558–66.
13. Lichtenstein D, Hulot JS, Rabiller A, Tostivint I,
Mezière G. Feasibility and safety of ultrasound-
aided thoracentesis in mechanically ventilated
patients. Intensive Care Med 1999;25:955–8.
14. Lichtenstein D, Lascols N, Mézière G,
Gepner A. Ultrasound diagnosis of alveolar
consolidation in the critically ill. Intensive Care
Med 2004;30:276–81.
15. Lichtenstein D. Lung ultrasound in the critically
ill. Ann Intensive Care 2014;4:1.
JACC: CARDIOVASCULAR IMAGING, VOL. 11, NO. 11, 2018
16. Brixey AG, Light RW. Pleural effusions occur-
ring with right heart failure. Curr Opin Pulm Med
2011;17:226–31.
17. Wiener-Kronish JP, Matthay MA, Callen PW,
et al. Relationship of pleural effusions to pulmo-
nary hemodynamics in patients with congestive
heart failure. Am Rev Respir Dis 1985;132:1253–6.
18. Tang K, Robbins IM, Light RW. Incidence of
pleural effusions in idiopathic and familial pul-
monary arterial hypertension patients. Chest
2009;136:688–93.
19. Luo Y, Robbins IM, Kataras M, et al. Incidence
of pleural effusions in patients with pulmonary
arterial hypertension associated with connective
tissue diseases. Chest 2011;140:42–7.
20. Ponikowski P, Voors AA, Anker SD, et al. ESC
guidelines for the diagnosis and treatment of
acute and chronic heart failure: the Task Force for
the Diagnosis and Treatment of Acute and Chronic
Heart Failure of the European Society of Cardiol-
ogy. Eur J Heart Fail 2016;18:891–975.
21. Kataoka H, Takada S. The role of thoracic ul-
trasonography for evaluation of patients with
decompensated chronic heart failure. J Am Coll
Cardiol 2000;35:1638–46.
22. Frassi F, Gargani L, Tesorio P, Raciti M,
Mottola G, Picano E. Prognostic value of extra-
vascular lung water assessed with ultrasound lung
comets by chest sonography in patients with
dyspnea and/or chest pain. J Card Fail 2007;13:
830–5.
23. Zoccali C, Torino C, Tripepi R, et al. Pulmonary
congestion predicts cardiac events and mortality
in ESRD. J Am Soc Nephrol 2013;24:639–46.
24. Gargani L, Pang PS, Frassi F, et al. Persistent
pulmonary congestion before discharge predicts
rehospitalization in heart failure: a lung ultrasound
study. Cardiovasc Ultrasound 2015;13:40.
25. Coiro S, Rossignol P, Ambrosio G, et al. Prog-
nostic value of residual pulmonary congestion at
discharge assessed by lung ultrasound imaging in
heart failure. Eur J Heart Fail 2015;17:1172–81.
26. Gustafsson M, Alehagen U, Johansson P. im-
aging congestion with a pocket ultrasound device:
prognostic implications in patients with chronic
heart failure. J Card Fail 2015;21:548–54.
27. Cogliati C, Casazza G, Ceriani E, et al. Lung
ultrasound and short-term prognosis in heart
failure patients. Int J Cardiol 2016;218:104–8.
28. Platz E, Lewis EF, Uno H, et al. Detection and
prognostic value of pulmonary congestion by lung
ultrasound in ambulatory heart failure patients.
Eur Heart J 2016;37:1244–51.
29. Miglioranza HM, Picano E, Badano L, et al.
Pulmonary congestion evaluated by lung ultra-
sound predicts decompensation in heart failure
outpatients. Int J Cardiol 2017;240:271–8.
30. Gundersen GH, Norekval TM, Graven T, et al.
Patient-reported outcomes and associations with
pleural effusions in outpatients with heart failure:
an observational cohort study. BMJ Open 2017;7:
e013734.
NOVEMBER 2018:1692–705
31. Morales-Rull JL, Bielsa S, Conde-Martel A,
et al. Pleural effusions in acute decompensated
heart failure: prevalence and prognostic implica-
tions. Eur J Intern Med 2018;52:49–53.
32. Picano E, Scali MC. The lung water cascade.
Echocardiography 2017;34:1503–7.
33. Lichtenstein D, Mézière G, Lagoueyte JF,
Biderman P, Goldstein I, Gepner A. A-lines and B-
lines: lung ultrasound as a bedside tool for pre-
dicting pulmonary artery occlusion pressure in the
critically ill. Chest 2009;136:1014–20.
34. Platz E, Jhund PS, Campbell ST, McMurray JJ.
Assessment and prevalence of pulmonary edema
in contemporary acute heart failure trials: a sys-
tematic review. Eur J Heart Fail 2015;17:906–16.
35. Torino C, Gargani L, Sicari R, et al. The agree-
ment between auscultation and lung ultrasound in
hemodialysis patients: the LUST study. Clin J Am
Soc Nephrol 2016;11:2005–11.
36. Platz E, Merz AA, Jhund PS, Vazir A,
Campbell R, McMurray JJ. Dynamic changes and
prognostic value of pulmonary congestion by lung
ultrasound in acute and chronic heart failure: a
systematic review. Eur J Heart Fail 2017;19:
1154–63.
37. Martindale JL, Wakai A, Collins SP, et al.
Diagnosing acute heart failure in the emergency
department: a systematic review and meta-anal-
ysis. Acad Emerg Med 2016;23:223–42.
38. Gargani L, Frassi F, Soldati G, Tesorio P,
Gheorghiade M, Picano E. Ultrasound lung comets
for the differential diagnosis of acute cardiogenic
dyspnoea: a comparison with natriuretic peptides.
Eur J Heart Fail 2008;10:70–7.
39. Liteplo AS, Marill KA, Villen T, et al. Emergency
thoracic ultrasound in the differentiation of the
etiology of shortness of breath (ETUDES): sono-
graphic B-lines and N-terminal pro-brain-type
natriuretic peptide in diagnosing congestive heart
failure. Acad Emerg Med 2009;16:201–10.
40. Wang HK, Tsai MS, Chang JH, Wang TD,
Chen WJ, Huang CH. Cardiac ultrasound helps for
differentiating the causes of acute dyspnea with
available B-type natriuretic peptide tests. Am J
Emerg Med 2010;28:987–93.
41. Nazerian P, Vanni S, Zanobetti M, et al. Diag-
nostic accuracy of emergency Doppler echocardi-
ography for identification of acute left ventricular
heart failure in patients with acute dyspnea:
comparison with Boston criteria and N-terminal
prohormone brain natriuretic peptide. Acad Emerg
Med 2010;17:18–26.

42. Prosen G, Klemen P, Strnad M, Grmec S.
Combination of lung ultrasound (a comet-tail sign)
and N-terminal pro-brain natriuretic peptide in
differentiating acute heart failure from chronic
obstructive pulmonary disease and asthma as
cause of acute dyspnea in prehospital emergency
setting. Crit Care 2011;15:R114.
43. Vitturi N, Soattin M, Allemand E, Simoni F,
Realdi G. Thoracic ultrasonography: a new method
for the work-up of patients with dyspnea.
J Ultrasound 2011;14:147–51.
JACC: CARDIOVASCULAR IMAGING, VOL. 11, NO. 11, 2018
NOVEMBER 2018:1692–705
44. Cibinel GA, Casoli G, Elia F, et al. Diagnostic
accuracy and reproducibility of pleural and lung
ultrasound in discriminating cardiogenic causes of
acute dyspnea in the emergency department.
Intern Emerg Med 2012;7:65–70.
45. Anderson KL, Jenq KY, Fields JM,
Panebianco NL, Dean AJ. Diagnosing heart failure
among acutely dyspneic patients with cardiac,
inferior vena cava, and lung ultrasonography. Am J
Emerg Med 2013;31:1208–14.
46. Russell FM, Ehrman RR, Cosby K, et al. Diag-
nosing acute heart failure in patients with undif-
ferentiated dyspnea: a lung and cardiac ultrasound
(LuCUS) protocol. Acad Emerg Med 2015;22:
182–91.
47. Pivetta E, Goffi A, Lupia E, et al. Lung ultra-
sound implemented diagnosis of acute decom-
pensated heart failure in the ED: a SIMEU
multicenter study. Chest 2015;148:202–10.
48. Sforza A, Mancusi C, Carlino MV, et al. Diag-
nostic performance of multiorgan ultrasound with
pocket-sized device in the management of acute
dyspnea. Cardiovasc Ultrasound 2017;15:16.
49. Ohman J, Harjola VP, Karjalainen P, Lassus J.
Rapid cardiothoracic ultrasound protocol for
diagnosis of acute heart failure in the emergency
department. Eur J Emerg Med 2017 Oct 3 [E-pub
ahead of print].
50. Agricola E, Picano E, Oppizzi M, et al.
Assessment of stress-induced pulmonary intersti-
tial edema by chest ultrasound during exercise
echocardiography and its correlation with left
ventricular function. J Am Soc Echocardiogr 2006;
19:457–63.
51. Simonovic D, Coiro S, Carluccio E, Girerd N,
Deljanic-Ilic M, Ambrosio G. Exercise elicits dy-
namic changes in extravascular lung water and
hemodynamic congestion in heart failure patients
with preserved ejection fraction. Eur J Heart Fail
2018;20:1366–9.
52. Nazerian P, Vanni S, Volpicelli G, et al. Accu-
racy of point-of-care multiorgan ultrasonography
for the diagnosis of pulmonary embolism. Chest
2014;145:950–7.
53. Song G, Bae SC, Lee YH. Diagnostic accuracy of
lung ultrasound for interstitial lung disease in
patients with connective tissue diseases: a meta-
analysis. Clin Exp Rheumatol 2016;34:11–6.
54. Chavez MA, Shams N, Ellington LE, et al. Lung
ultrasound for the diagnosis of pneumonia in
adults: a systematic review and meta-analysis.
Respir Res 2014;15:50.
55. Alrajab S, Youssef AM, Akkus NI, Caldito G.
Pleural ultrasonography versus chest radiography
for the diagnosis of pneumothorax: review of
literature and meta-analysis. Crit Care 2013;17:
R208.
56. Havelock T, Teoh R, Laws D, Gleeson F, BTS
Pleural Disease Guideline Group. Pleural proced-
ures and thoracic ultrasound: British Thoracic So-
ciety pleural disease guideline 2010. Thorax 2010;
65 Suppl 2:II61–76.
57. Dancel R, Schnobrick D, Puri N, et al. Recom-
mendations on the use of ultrasound guidance for
adult thoracentesis: a position statement of the
Society of Hospital Medicine. J Hosp Med 2018;13:
126–35.
58. Sicari R, Galderisi M, Voigt UJ, et al. The use of
pocket-size imaging devices. A position statement
of the European Association of Echocardiography.
Eur J Echocardiogr 2011;12:85–97.
59. Neskovic AN, Hagendorff A, Lancellotti P,
et al. Emergency echocardiography: the European
Association of Echocardiography recommenda-
tions. Eur Heart J Cardiovasc Imaging 2013;14:1–11.
60. Mebazaa A, Yilmaz MB, Levy P, et al. Rec-
ommendations on pre-hospital and early hospital
management of acute heart failure: a consensus
paper from the Heart Failure Association of the
European Society of Cardiology, the European
Picano et al. 1705
Heart-Driven Lung Ultrasound
Society of Emergency Medicine and the Society of
Academic Emergency Medicine–short version. Eur
Heart J 2015;36:1958–66.
61. Price S, Platz E, Cullen L, et al. Echocardiog-
raphy and lung ultrasonography for the assess-
ment and management of acute heart failure.
Expert consensus document for the Acute Heart
Failure Study Group of the European Society of
Cardiology Acute Cardiovascular Care Association.
Nat Rev Cardiol 2017;14:427–40.
62. Lancellotti P, Pellikka PA, Budts W, et al.
Recommendations for the clinical use of stress
echocardiography in non-ischemic heart disease:
joint document of the European Association of
Cardiovascular Imaging and the American Society
of Echocardiography. Eur Heart J Cardiovasc Im-
aging 2016;17:1191–229.
63. Stolz L, O’ Brien KM, Miller MM, et al. A review
of lawsuits related to point-of-care emergency
ultrasound applications. West J Emerg Med 2015;
16:1–4.
64. Picano E, Ciampi Q, Citro R, et al. Stress echo
2020: the international stress echo study in
ischemic and non-ischemic heart disease. Car-
diovasc Ultrasound 2017;15:3.
65. Picano E, Vano E, Rehani MM, et al. The
appropriate and justified use of medical radiation
in cardiovascular imaging: a position document of
the ESC Associations of Cardiovascular Imaging,
Percutaneous Cardiovascular Interventions and
Electrophysiology. Eur Heart J 2014;35:665–72.
KEY WORDS chest sonography,
echocardiography, pleural effusion,
pulmonary congestion, thoracic ultrasound
A PPE NDI X For a supplemental video,
please see the online version of this paper.